Provider Demographics
NPI:1982935540
Name:NICOLUSSI, AMANDA ELIZABETH (MOT, OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:ELIZABETH
Last Name:NICOLUSSI
Suffix:
Gender:F
Credentials:MOT, OTR/L
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:ELIZABETH
Other - Last Name:HASELTINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9357 GENERAL DR
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-4662
Mailing Address - Country:US
Mailing Address - Phone:734-454-0866
Mailing Address - Fax:
Practice Address - Street 1:9357 GENERAL DR
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-4662
Practice Address - Country:US
Practice Address - Phone:734-454-0866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-21
Last Update Date:2013-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056.008910225XP0200X
MI5201008235225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist